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A Two Day Old Term Infant Begins to Feed Poorly and Her Exam is Significant for Weak Cry

Ditulis Senin, 10 Oktober 2022 Tulis Komentar Edit

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Infants are usually born at term between 37 and 42 weeks of gestation. This time period can be further divided into early term (37 to 38 weeks), full term (39 to 40 weeks), and late term (41 weeks) deliveries. After 42 weeks of gestation, birth is considered postterm. Approximately 10% of births are preterm, occurring prior to 37 completed weeks of pregnancy. Most infants born at term require very little medical attention in order to successfully adapt to extrauterine life. Routine management of a newborn infant immediately after birth consists of removing airway secretions, drying the newborn, and providing him or her with warmth. Health care providers also clamp and cut the umbilical cord. The Apgar score is typically used to gauge the clinical status of newborn infants at one and five minutes after birth using the following parameters: heart rate, respiratory effort, muscle tone, reflex irritability to tactile stimulation, and skin color. Infants who are born at term or late preterm and are breathing and moving satisfactorily should immediately be given to their mother for skin-to-skin contact and initiation of breastfeeding. Infants who are born prematurely, lack muscle tone, or are not breathing or crying may require supplemental oxygen or neonatal resuscitation.

Preventive medicine measures in the delivery room include the administration of ophthalmic antibiotics and vitamin K. Within 24 hours of birth, a detailed assessment of the newborn should take place. This typically includes a history of the pregnancy and a physical exam from head to toe, as well as measurements of length and weight.

Apgar score [9]

  • Used for standardized clinical assessment of newborns at 1 and 5 minutes after birth
  • Assessing the need for and beginning neonatal resuscitation should be done independently of and before the Apgar score is determined
  • Assessment of the Apgar score at 5 minutes: infants with scores < 7 may require further intervention
    • Reassuring: 7–10
    • Moderately abnormal: 4–6
    • Low: 0–3
  • In infants with a score below 7, the Apgar assessment is performed at 5–minute intervals for an additional 20 minutes.
  • Persistently low Apgar scores are associated with long-term neurologic sequelae.
Calculation of the Apgar score
0 Points 1 Point 2 Points
Appearance (skin color) Blue (cyanotic) or pale Pink trunk, blue extremities (acrocyanosis) Pink body and extremities
Pulse (heart rate) None < 100 beats/min ≥ 100 beats/min
Grimace (reflex irritability upon tactile stimulation) None Grimace Cry or active withdrawal
Activity (muscle tone, movement) No movement, limp body Some flexion Active motion, flexion
Respirations None Weak cry, irregular/slow/weak breathing or gasping Regular breathing, strong cry

APGAR: Appearance, Pulse, Grimace, Activity, Respirations

The Apgar score is useful for evaluating the status of a newborn infant, but it should not be used to draw conclusions about individual neonatal morbidity or mortality and it should not be used as a long-term prognostic tool.

Preventive measures directly after birth

  • Ophthalmic antibiotics: to prevent gonococcal conjunctivitis (erythromycin ophthalmic ointment)
  • Vitamin K: to prevent vitamin K deficiency bleeding of the newborn (VKDB)

Measurement and a detailed examination of the newborn should take place within the first 24 hours of life . See "Clinical relevance" for examples of pathological findings of a newborn examination.

The physiological respiratory rate and heart rate of newborns are substantially higher than in adults and older pediatric patients.

Healthy newborns normally lose up to 7% of their original birth weight in the first 5 days of life. This weight is then gained back through drinking breast milk and/formula by age 10–14 days . No treatment is necessary.

Erythema toxicum neonatorum

  • Definition : : a benign, self-limiting rash that appears within the first week of life
  • Etiology : unknown (probable contributing factors: immature sebaceous glands and/or hair follicles )
  • Clinical features
    • Small, red macules and papules that progress to pustules with surrounding erythema
    • Located on trunk and proximal extremities
    • Spares the palms of hands and soles of feet
  • Diagnostics
  • Treatment : observation only
  • Prognosis : : typically resolves without complications within 7–14 days

Congenital dermal melanocytosis (Mongolian spot)

  • Definition: benign blue-gray pigmented skin lesion of newborns
  • Neonatal prevalence [21]
  • Pathophysiology: melanocytes migrating from the neural crest to the epidermis during development become entrapped in the dermis
  • Clinical features
  • Diagnostics
  • Prognosis : : usually resolves spontaneously during childhood (typically by the age of 10 years ) [22]

Congenital melanocytic nevus

  • Definition: a congenital skin lesion caused by the proliferation of melanocytes
  • Epidemiology: 1/20,000 births [23]
  • Clinical features ; [23]
    • Light to darkly pigmented, well-circumscribed macule or patch
    • Often with increased hair growth
    • Vary in size: < 1.5 cm to > 20 cm
    • A nevus larger than 20 cm in size is referred to as a giant congenital melanocytic nevus
  • Treatment: surgical excision or laser ablation (depending on type and size of lesion)
  • Prognosis: large nevi are at risk of degeneration → frequent follow-up

Infantile hemangioma (strawberry hemangioma)

  • Definition: benign capillary vascular tumor of infancy
  • Epidemiology
    • Occurs in 3–10% of infants [24]
    • Mostly affects girls
  • Pathophysiology
    • Abnormal development of vascular endothelial cells
    • Rapid proliferation followed by subsequent spontaneous slow involution (occurring at the age of 5–8 years) [25]
  • Clinical features
    • Manifests during the first few days to months of life
    • Progressive presentation ; : blanching of skin → fine telangiectasias → red painless papule or macule (strawberry appearance)
    • Most commonly on he ad and neck
    • Usually solitary lesions
  • Diagnostics
  • Treatment
  • Complications
  • Prognosis
    • Usually good prognosis
    • Spontaneous resolution is common
    • Visual impairment if periorbital hemangioma is left untreated

Some congenital infections may manifest with rashes or other skin conditions and should be differentiated from benign skin lesions in the newborn.

  • In the US, each state has its own newborn screening program, and the conditions screened for vary from state to state.
  • The U.S. Department of Health and Human Services has made some recommendations, for a comprehensive list of recommended uniform screening panels, see the "Tips & links" section.
  • Most of the tests are performed on filter paper using a few drops of blood from a newborn's heel.
  • Optimal time for screening: 36–72 hours after birth

Examples of commonly screened conditions

  • Endocrine conditions
    • Congenital hypothyroidism
    • Congenital adrenal hyperplasia
  • Metabolic conditions
    • Disorders of fatty acid metabolism
    • Disorders of organic acid metabolism (e.g., isovaleric acidemia, methylmalonic acidemia, propionic acidemia)
    • Disorders of amino acid metabolism ; (e.g., phenylketonuria, homocystinuria, maple syrup urine disease , citrullinemia type I )
  • Hemoglobinopathies (e.g., sickle cell disease, beta thalassemia)
  • Other conditions
    • Hearing loss (otoacoustic emissions and/or auditory brainstem response)
    • Critical congenital heart defects (pulse oximetry)
    • Cystic fibrosis
    • Classical galactosemia
    • Severe combined immunodeficiencies (SCID)
    • Glycogen storage disease type II (Pompe disease)
    • Mucopolysaccharidosis type I
    • X-linked adrenoleukodystrophy
    • Spinal muscular atrophy
    • Biotinidase deficiency
      • Etiology: metabolic disorder that leads to biotin deficiency
      • Clinical features: dermatitis, CNS damage
      • Treatment: biotin substitution
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